The nation’s first mandated job requirement for Medicaid recognition, approved by a Republican-led Congress and signed by President Trump, is expected to have a seismic effect in California.
One estimate from the state health officials suggests that as many as 3.4 million people can lose their insurance through what Gavin Newsom calls the “manual verification maze.”
“We’re a 2.3 million MEDI-CAL patients,” said Martha Santanatin, head of an open health plan that serves around 2.3 million MEDI-CAL patients in Los Angeles County.
She said that as many as 1 million people, or about 20% to 40% of their members, could lose coverage.
Work requirements are the first nationwide imposed in the six-year Medicaid history, a program that provides free and subsidized health insurance to disabled and low-income Americans.
It is a relatively unknown territory, and it is not yet clear how the California 5.1 million rules required to prove that they are working to qualify for Medi-Cal, the state’s Medicaid version, is shaken.
After the 2026 midterm elections, every six months, millions of healthy adults need to prove they meet job requirements to qualify for Medicaid. The new mandate spells out a few exceptions, including pregnant people, addiction treatment, or caring for children under the age of 14.
Democrats have long argued that job requirements generally lead to eligible people who are eligible to take health insurance due to bureaucratic hurdles. Republicans say job requirements encourage healthy people to get jobs and encourage Medicaid to stay for those who really need it.
“If you clean it and clean it, you save a lot of money,” said Louisiana House Speaker Mike Johnson. “And you’re going back to the dignity of your work, a young man who needs to work instead of playing video games all day.”
Only US states that have attempted to implement work requirements for Medicaid recipients in New Hampshire, Arkansas and Georgia. One study found that over 18,000 people lost their health insurance in the first three months of the Arkansas program.
Joan Alker, a professor at Georgetown University who studies Medicaid, said people could lose coverage in a variety of ways. Some people have heard that the rules have been changed and assume they are no longer eligible. Others struggle to prove eligibility because their income fluctuates, they are paid in cash, and their jobs don’t have good pay records. She said some have problems with technology and form, while others don’t plead for rejection.
Of the 15 million people in California’s Medi-Cal, about a third need to prove they’re at work, the state said. Those people make little money: under $21,000 per person and under $43,000 for four households.
Estimating the state’s 3.4 million range is a prediction based on what happened in Arkansas and New Hampshire.
But these programs are short, overturned by the courts and not “interstate coordinated efforts to understand what best practices are,” said Ryan Long, director of the Paragon Health Institute, an influential and conservative think tank among Congressional Republicans.
Long should be less barriers to job verification if he places a national emphasis on technological advancements and job requirements. The budget bill includes a state $200 million grant to update the system it prepares, he said.
The argument from liberal groups that people lose health care is a “strowman argument,” Long said: “They know that they support the requirements of work for these benefits, so they can’t come out and say, ‘We don’t support them’.”
Voting by Health Research Group KFF found this year that 62% of American adults support Medicaid eligibility with work requirements.
The vote also found that respondents reduced to less than one in three respondents saying “most people in Medicaid are already working, and many are at risk of losing compensation due to the burden of certifying eligibility through paperwork.”
In June, Newsom warned that some Californians could be forced to fill out 36-page documents to maintain their insurance. The reporter shows an image of a stack of teal and gold accents, described as “an actual PDF example of documents people have to submit for qualification checks.”
Many Californians need to fill out the 36-page form or the online equivalent of its online.
Experts say it’s too early for people to say which systems will be used to prove their job eligibility, as federal guidance is not confirmed for months.
Newsom’s office turned questions to the Ministry of Health Services, which runs Medi-Cal. There, the spokesman said officials were “still reviewing the full operational impact” of work requirements.
“The idea of getting a paper submission every six months doesn’t know if people have to do that,” Long said.
Georgia is the only state that has implemented Medicaid permanent work requirements. Two years ago, the state made healthcare available to people who work at least 80 hours a month and earn fewer people than the federal government’s poverty limit (about $15,000 per person and $31,200 for four households).
More than 100,000 people have applied for compensation since the program began in July 2023, according to state’s latest data.
The Medicaid program has so far cost more than $100 million, of which $26 million has been spent on health benefits and more than $20 million has been allocated to marketing agreements, KFF Health News reported. Georgia Democrats are calling for an investigation into the program.
The Inland Imperial Office, which provides MEDI-CAL coverage for around 1.5 million people in San Bernardino and Riverside counties, estimated that 150,000 members could lose insurance as a result of labor requirements.
Jarrod McNaughton, CEO of the Inland Empire Health Plan, said the 58 California counties that manage Medi-Cal are “on the cliffs that we’re stitching together,” but said they haven’t yet received guidance on how the eligibility process will be set up or on the information people will be provided.
Will it be done online? Do recipients need to fill out a piece of paper that needs to be mailed or dropped off? “We don’t really know this process yet, because this is all very new,” Norton said.
In the meantime, the Health Planning Foundation is working to make this a “lowest possible burden,” to improve community outreach and connect people who receive medical insurance to volunteer opportunities.
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